title: Selective nonoperative management of leaks after gastric bypass: lessons learned from 2675 consecutive patients.
abstract: OBJECTIVE
  To compare outcomes of patients with leaks after primary Roux-en-Y gastric bypass (GBP) managed operatively with those managed nonoperatively and subsequently derive indications for selective nonoperative management.
  
  
  BACKGROUND
  There is no consensus on the management of leaks complicating GBP, which remains the commonest cause of death.
  
  
  METHODS
  We evaluated 2675 consecutive GBP procedures, determining incidence and outcomes of leaks in a program emphasizing early detection, routine drainage, and selective nonoperative management.
  
  
  RESULTS
  Leaks occurred in 46 patients (41 women) with mean (+/-SD) age of 46.9 +/- 8.7 years, weight and body mass index (BMI) of 307.8 +/- 56.9 lb and 51.2 +/- 9.5 kg/m, respectively. Leaks were initially identified by upper gastrointestinal contrast swallow (UGI) on the first postoperative day (22), abnormal drain output (11), delayed UGI (3), or on clinical suspicion (10) with a respective interval to diagnosis of 1.1*, 6.5, 7, and 7.9 days (*P < 0.007 vs. other groups). Leaks were located in the gastrojejunal (GJ) anastomosis (37), gastric pouch (4), gastric remnant (2), jejuno-jejunostomy (1), Roux limb (1), and cervical esophagus (1), and were radiologically contained (40) or diffuse (3) or not demonstrable (3). Contained leaks were treated nonoperatively (31), by operation (7), or required no treatment (2). Patients with diffuse leaks or bilious drain output were operatively managed. They were similar in duration for nil per oral order, drain and antibiotic use and readmission rates, whereas hospital stays were longer in the operative group, P < 0.01. There were no deaths.
  
  
  CONCLUSIONS
  Many leaks after gastric bypass are radiologically contained GJ and pouch leaks and can be safely managed nonoperatively. Radiologic features and bilious drainage were key determinants of treatment, with operative treatment used for diffuse GJ leaks, bilious drainage, or clinical suspicion with a negative UGI. Outcomes were similar in both groups.
authors.affiliation: Department of Surgery, New York Methodist Hospital, Brooklyn, New York 11215, USA. pthodiyil@gmail.com
authors.forename: Paul A
authors.initials: PA
authors.lastname: Thodiyil
authors.forename: Panduranga
authors.initials: P
authors.lastname: Yenumula
authors.forename: Tomasz
authors.initials: T
authors.lastname: Rogula
authors.forename: Piotr
authors.initials: P
authors.lastname: Gorecki
authors.forename: Bashar
authors.initials: B
authors.lastname: Fahoum
authors.forename: William
authors.initials: W
authors.lastname: Gourash
authors.forename: Ramesh
authors.initials: R
authors.lastname: Ramanathan
authors.forename: Samer G
authors.initials: SG
authors.lastname: Mattar
authors.forename: Dilip
authors.initials: D
authors.lastname: Shinde
authors.forename: Vincent C
authors.initials: VC
authors.lastname: Arena
authors.forename: Leslie
authors.initials: L
authors.lastname: Wise
authors.forename: Philip
authors.initials: P
authors.lastname: Schauer
mesh_terms: D018806:APACHE; D000465:Algorithms; D000714:Anastomosis, Surgical; D015992:Body Mass Index; D015897:Comorbidity; D004322:Drainage; D005260:Female; D015390:Gastric Bypass / Q000009:adverse effects*; D006801:Humans; D010535:Laparoscopy; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D009767:Obesity, Morbid / Q000453:epidemiology / Q000601:surgery; D011183:Postoperative Complications / Q000628:therapy